An inter-subjective multi-factorial model of auditory verbal hallucinations in schizophrenia

Auditory verbal hallucinations (AVHs) are perceptive-like experiences happening without appropriate stimuli that in individuals with schizophrenia very often feature distressing contents. AVH frequently interfere with social relationships or result in dangerous behaviours. We hypothesize that in schizophrenia several vulnerability factors, especially when a subject is engaged in real or represented interpersonal transactions, lead to the appearance of AVHs, and favour their self-perpetuation over time. We analyse the different psychological factors that, according to empirical studies and clinical experience with persons with schizophrenia, seem involved in the genesis of AVHs. Several vulnerability factors appear to interact with situational ones to trigger AVHs: a) a facilitation of neural transmission from the premotor regions to the perceptual ones; b) a difficulty attuning with others, c) interpersonal schemas, provoking emotional suffering, intrusive thoughts and rumination; d) metacognitive dysfunctions. Once AVHs have appeared, further factors promote their perpetuation over time: a) cognitive factors like ruminative processing on AVHs, b) metacognitive beliefs about AVHs. An integrated theoretical model of AVHs is described and ideas for its empirical testing are suggested.     

Attention Training With Auditory Hallucinations: A Case Study

The case presented in this paper illustrates how Attention Training (ATT; [Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy, 21, 273–280.]) can be applied in an outpatient setting in the treatment of auditory hallucinations. The 25-year-old male patient presented had a 4-year history of schizophrenia and treatment-refractory auditory hallucinations. He had received cognitive behavior therapy (CBT) before starting ATT. CBT had changed his attribution of the voices, and when he started with ATT the patient no longer held the belief that “voices are dangerous,” but his processing configuration was still acting “as if” the voices were a source of threat: He would listen to them, ruminate about them, and was easily distracted by them. Eight sessions of ATT resulted in a reduction of symptoms and in a dramatic change in the perceived control and mastery of the auditory hallucinations. It is concluded that ATT may be a helpful adjunct strategy in the treatment of specific psychotic symptoms.     

Beliefs about hearing voices

People who experience auditory verbal hallucinations (AVHs) vary in whether they believe their AVHs are self-generated or caused by external agents. It remains unclear whether these differences are influenced by the “intensity” of the voices, such as their frequency or volume, or other aspects of their phenomenology. We examined 35 patients with schizophrenia or schizoaffective disorder who experienced AVHs. Patients completed a detailed structured interview about their AVHs, including beliefs about their cause. In response, 20 (57.1%) reported that their AVHs were self-generated, 9 (25.7%) were uncertain, and 6 (17.1%) reported that their AVHs were caused by external agents. Several analytical approaches revealed little or no evidence for associations between either AVH intensity or phenomenology and beliefs about the AVH’s cause; the evidence instead favoured the absence of these associations. Beliefs about the cause of AVHs are thus unlikely to be explained solely by the phenomenological qualities of the AVHs.     

Metacognitive Therapy Focused on Psychosocial Function in Psychosis

Metacognitive Insight and Reflection Therapy is a manual-based individual psychotherapy aimed at enhancing four metacognitive processes through patient’s personal narratives which may promote recovery by helping individuals suffering from schizophrenia to develop a richer and more integrated sense of self. This study is a single case analysis of the effects of a meta-cognitively oriented CBT on residual psychotic symptoms and functional targets. Outcome measures (PANNS, PDI 21, BAVQ-R, PSP, MAS-A) were collected at two different times: pre-CBT and 1-year. Results showed reductions in the distress, preoccupation and conviction associated with delusions and improvements in metacognitive abilities, social functioning, hopefulness and of the sense of self-confidence to cope with the psychotic symptoms. Adopting a metacognitive perspective during psychotherapy had several benefits: to foster the development of therapeutic alliance, to allow the patient to assess the efficacy and acknowledge the consequences of the different strategies he could use to cope with his symptoms and to question the predominance of his delusions in his life. To conclude, Metacognitive Reflection and Insight Therapy seem particularly adapted to address psychosocial issues, such as social or work functioning.     

The roles of thought suppression and metacognitive beliefs in proneness to auditory verbal hallucinations in a non-clinical sample

In a non-clinical sample (N = 751), we investigated relations among two subscales (self-reported intrusiveness of unwanted thoughts and thought suppression) of the White Bear Suppression Inventory (WBSI), metacognitive beliefs, and proneness to auditory verbal hallucinations (AVHs). Both subscales of the WBSI were found to be related to AVH-proneness and strongly positively related to metacognitive beliefs about the uncontrollability and danger of thoughts. Regression analyses were used to test models of the relations among AVH-proneness and a range of metacognitive beliefs. When the WBSI subscale relating to the self-reported intrusiveness of unwanted thoughts was controlled for, the metacognitive style that was the strongest predictor of AVH-proneness was cognitive self-consciousness. Cognitive confidence and beliefs about the uncontrollability of thoughts were also significant predictors of AVH-proneness. These findings are used to revise existing models of the relations between metacognitive beliefs and AVHs. Implications for the management of AVHs are discussed.     

The roles of thought suppression and metacognitive beliefs in proneness to auditory verbal hallucinations in a non-clinical sample

In a non-clinical sample (N = 751), we investigated relations among two subscales (self-reported intrusiveness of unwanted thoughts and thought suppression) of the White Bear Suppression Inventory (WBSI), metacognitive beliefs, and proneness to auditory verbal hallucinations (AVHs). Both subscales of the WBSI were found to be related to AVH-proneness and strongly positively related to metacognitive beliefs about the uncontrollability and danger of thoughts. Regression analyses were used to test models of the relations among AVH-proneness and a range of metacognitive beliefs. When the WBSI subscale relating to the self-reported intrusiveness of unwanted thoughts was controlled for, the metacognitive style that was the strongest predictor of AVH-proneness was cognitive self-consciousness. Cognitive confidence and beliefs about the uncontrollability of thoughts were also significant predictors of AVH-proneness. These findings are used to revise existing models of the relations between metacognitive beliefs and AVHs. Implications for the management of AVHs are discussed.     

Restoring Dyadic Connection in the Face of Multiple Disruptions: Accounting for Vicissitudes in the Therapist’s Capacity for Reflective Functioning

This article describes the working method of our study group comprised of former Chestnut Lodge Hospital therapists and focusing on understanding therapeutic work with severely disturbed adolescents. Using process material from one therapy session, the therapist’s commentary on her feelings and reactions in the session, and the group’s discussion of the work, we explore factors disrupting the therapist’s moment-to-moment capacity to maintain a theory of her own and the patient’s minds. We then discuss what allows her to refind her theory of mind in the face of the patient’s aggressive nihilism and her own sense of loss. Salutary factors included the therapist’s empathy for the patient’s shared sense of grief, the patient’s offering the therapist cues to his inner state, and the dyad’s capacity to tolerate the therapist’s vulnerability in the patient’s presence.     

Immediate source-monitoring, self-focused attention and the positive symptoms of schizophrenia

Previous research suggests that tendencies to misattribute one's own thoughts to an external source, as assessed by an immediate source-monitoring test, are associated with auditory verbal hallucinations (AVHs). However, recent research suggests that such tendencies are associated instead with symptoms of thought interference. The main aim of the present study was to examine whether such tendencies are differentially associated with different types of thought interference, with AVHs, or with both. It has also been suggested that external misattributions are especially likely to occur with emotionally salient material and if the individual's focus is on the self. These suggestions were also tested. The positive psychotic symptoms of 57 individuals with a diagnosis of schizophrenia were assessed and they then completed the Self-Focus Sentence Completion blank. Immediately after completing each sentence they were asked to indicate to what extent the sentence was their own. The number of sentences that were not rated as completely their own served as their externalisation score. Externalisation scores correlated significantly with the severity of three symptoms: voices commenting, delusions of being controlled, and thought insertion. In a logistic regression analysis, all three of these symptoms were significantly and independently related to externalisation. Externalisation was not associated with either a negative or a neutral self-focus. Thus tendencies to misattribute one's own thoughts to an external source are associated with AVHs and some, but not all, symptoms of thought interference. The importance for externalisation of self-focused attention and of the emotional salience of the elicited thoughts was not supported.     

Auditory Hallucinations as Social Self-Positions: A Theoretical Discussion from a Single-Case Study

This work uses social positioning analysis to investigate the phenomenon of the auditory verbal hallucination (AVH) in schizophrenia in order to describe its social and interactive nature. We focus in detail on a single-case study of a patient who verbalized her AVHs. We analyze 3 significant excerpts from an interview with a person with paranoid schizophrenia. This interview is part of a larger study conducted with 18 participants about life narrative construction in the sociocultural context of care homes. The interaction between the patient and her voices is examined closely to reveal the dynamic between interviewer, patient, and voices. The analysis differentiates the voice of the patient from that of the hallucination and reveals “social interaction” between this dyad and the interviewer. We discuss a possible social and interactive framework to understand the origin of AVHs and the self-construction process.     

Metacognitive Reflective and Insight Therapy for a Person Who Gained Maximal Levels of Metacognitive Capacity and Was Able to Terminate Therapy

Schizophrenia often involves a loss of metacognitive capacity, or the ability to form a complex and integrated sense of self and others. Independent of symptoms and impairments in neurocognition, metacognitive deficits are a barrier to the formation and sustenance of goal-directed activities of daily life and ultimately to recovery. Metacognitive reflective and insight therapy (MERIT) is a form of psychotherapy intended to assist patients to recover metacognitive capacity through intensive individual therapy. This paper presents a case illustration of how MERIT assisted a patient with prolonged schizophrenia and significant metacognitive deficits to develop a robustly complex understanding of himself and others and then to use that knowledge to agentically monitor his own experiences and effectively respond to life challenges. The eight elements of MERIT that stimulate and promote metacognitive capacity are presented with an emphasis on how they were implemented when the patient had reached some of the higher levels of metacognitive function.     

Inside out,or outside in: meeting with couples

The complex difficulties often faced by couples require a range of models for effective help. Relational intensity is heightened in therapy by the ease with which the therapist can be triangled into the couple's relationship and by the influence of the emotional triggers from their respective internal worlds. This article draws on systemic and psychodynamic models and a transgenerational perspective for gendered stories. Different time frameworks link interpersonal and intrapersonal themes. In this sense, the therapist works ‘inside out’ and ‘outside in’. A framework of behaviours, emotions, feelings, meanings and beliefs is proposed to help link these perspectives. ‘Invisible contracts’ and the sense of there often being an unconscious ‘pact to disappoint’ are described. Clear models are not enough, for it is the intimate encounter between client and therapist that is the bedrock of therapeutic change and growth. There is no short cut to this sense of intimacy in the unique encounter between therapist and each new couple. Brief examples from practice describe how the issues discussed may be addressed in couples work.     

Auditory Verbal Hallucinations as Dialogical Experiences

The purpose of this study is to offer a model in which auditory verbal hallucinations (AVHs) can be conceptualized as dialogical experiences. This model is of interest in that it integrates several different perspectives (phenomenological, cognitive, social, and evolutionary) and the findings of empirical research on the subject. Hallucinations are understood as the product of a state of consciousness in which the self is dissociated into different positions or perspectives. After reviewing the most relevant results of psychological research, dialogical self theory is proposed as the theoretical framework for understanding hallucinatory experiences. It is argued that the voices possess a series of characteristics, pragmatic properties, relationships with the voices similar to their social surroundings, and more dissociative experiences in people who experience voices than in those who do not, with which they may be considered a dialogical experience. Finally, a model attempting to integrate psychological research on AVHs within the framework of dialogical self theory is presented.     

Interpretations of voices in patients with hallucinations and non-patient controls: a comparison and predictors of distress in patients

BACKGROUND: This study tested the hypotheses that interpretations of voices will be associated with distress linked to auditory hallucinations, and that patients experiencing hallucinations will exhibit higher levels of negative interpretations in comparison with non-patients. METHOD: The Interpretation of Voices Inventory (British Journal of Clinical Psychology 41 (2002) 259) was administered to patients who met DSM-IV criteria for schizophrenia spectrum disorders with auditory hallucinations and non-patients. Patients were also assessed using a semi-structured interview to asses clinical dimensions of their voices. RESULTS: The results showed that people with psychosis who experience auditory hallucinations did exhibit higher levels of positive and negative interpretations of voices, in comparison to non-patients. Correlational analyses revealed that interpretations of voices were significantly associated with emotional, physical and cognitive characteristics of voices. Regression analyses demonstrated that physical characteristics of voices and metaphysical beliefs were significant predictors of emotional characteristics of voices. CONCLUSIONS: The theoretical and clinical implications of these findings are discussed.     

A phenomenological survey of auditory verbal hallucinations in the hypnagogic and hypnopompic states

The phenomenology of auditory verbal hallucinations (AVHs) occurring in hypnagogic and hypnopompic (H&H) states has received little attention. In a sample of healthy participants (N = 325), 108 participants reported H&H AVHs and answered subsequent questions on their phenomenology. AVHs in the H&H state were found (1) to be more likely to only feature the occasional clear word than to be clear, (2) to be more likely to be one-off voices than to be recurrent voices, (3) to be more likely to be voices of people known to the individual than unknown persons, (4) to be more likely to talk directly to the person rather than not, and (5) to only rarely give commands, ask questions, or to result in an interactive conversation. Their phenomenology was similar to normative AVHs in wakefulness (as established by previous research) in that the voice-hearer was usually the target of the voice, and the voice was more likely to be of a recognized person. However, H&H AVHs differed from AVHs in wakefulness in that commands and questions were rare, and there was typically no dialogical engagement with the voice. We conclude by proposing that two distinct types of H&H AVHs may exist (which we term “dialogic” and “monologic”), based on an analysis of the phenomenology of the experience, and suggest avenues for future research.     

“Am I Going Crazy,Doc?”: A Self Psychology Approach to Therapeutic Assessment

In this case study, we explore the effectiveness of Therapeutic Assessment with a severely disturbed 25-year-old man, referred by his therapist, following Finn's (2007; Finn & Tonsager, 1992, 1997) model. This patient–therapist pair had been working together for approximately 2 months, but the therapy had ceased to progress. The therapist requested a clearer picture of his patient's affective functioning, interpersonal functioning, and self-functioning that might facilitate more effective treatment. Through a collaborative assessment process informed by the principles of Kohutian self psychology, the evaluator and patient slowly formed a working alliance that proved useful for the eventual communication to the patient of his psychologically tenuous reality. This case illustrates the utility of a collaborative, multimethod Therapeutic Assessment with a severely ill patient and the use of Therapeutic Assessment by a less experienced clinician.     

Therapie und Theater

Theatre experience serve in drama therapies only as a background for a better understanding of the patients problems, whereas the dialogue between therapy and theatre contributes to the understanding of the process of therapy itself and the secrets of it’s effect. As the actor creates an “empty space” to express himself, so tries a therapist to eliminate all obstructions of understanding. Both dedicate their whole personality to the author respectively to the patient, which requires an enormous amount of humility and responsibility and can be achieved only by a continuous argument with himself. The closeness of profession and personal life is therefore unavoidable, which means various possibilities and impulses but great dangers as well. Therapy and theatre are not to compare with any other interpersonal relationship, for they are trying to achieve changes in the way of feeling, thinking and acting. Whether, on this way, the therapist’s and actor’s real emotional expression is more important than the rational analysis of all emotions or not, is a question often discussed controversially. Just like in a child’s play, it is always about the argument between fantasy and reality and, therefore, about the stimulation and development of the audience’s and the patient’s creativity. Therefore it is of greatest importance for the therapy as for the theatre that the process is immediate, vivid and unforeseen. They are paths towards life, experiencing their purpose and limits through this task.     

When Time Stands Still: The Non-Interactive Interaction in the Psychoanalytic Encounter

This paper strives to shed light on the patient–therapist encounter at times and places where emotional life has stopped, both within the patient and in the therapeutic dyad. The term non-interactive interaction is coined to describe a manner of being together that does not possess the essential features of interaction: movement, encounter, and change. The paper explores the characteristics and effects of such dead areas in one’s soul and the various motivations for the therapist’s willingness to surrender himself to such areas, both those of his patient’s and of his own. Among these, the paper suggests, are the therapist’s love and dedication to his or her patients; his deep-rooted struggle to cope with and give life to some of his own deadened and traumatic self-states; and, perhaps most important, a mythical, hubris-like, valiant, and perennial urge to fight death. Two clinical examples are presented.     

Exploring In-Session Process with Qualitative and Quantitative Methods in Psychotherapy with an Adolescent

ABSTRACT

There is emerging evidence for the effect of psychotherapy in adolescents with depression. Research indicates that therapists often use techniques from different theoretical models when working with adults. Research on the therapy process in adolescents is scarce. We explore the therapist’s interventions in a time-limited psychodynamic adolescent therapy with Susanna suffering from major depression. Susanna quite suddenly became worse at mid-treatment, with self-harming and suicidal ideations. Rating scales for analyzing in-session relational processes included the Structural Analysis of Social Behavior (SASB), the Adolescent Psychotherapy Q-set (APQ), and the Transference Work Scale (TWS). Self-reports on symptoms, interpersonal problems, and working alliance were obtained before, during, and at the end of and one year after treatment. Different tools seemed to expose different aspects of the process and the patient’s development. Only patient-rated questionnaires revealed the mid-treatment crises. Combining different and pan-theoretical rating scales on here-and-now interventions (TWS and SASB) and whole sessions (APQ), as well as clinician-rated measures and a variety of self-reports, indicated that different psychotherapeutic techniques were integrated in the therapy and seemed beneficial to patient’s outcome. The therapist adhered to the treatment manual. This way of exploring the therapy process may be used for different treatment modalities.     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.